Aim
Intensive Care at Home (ICAH) may have Clients requiring specialised nursing care to manage urinary catheters for long term or intermittent support of the urinary system as well as intermittent catheterization to manage urine retention. The aim of this policy is to guide ICAH Critical Care Nurses (CCRNs) to :
- Maintain infection prevention and control procedures for insertion, maintenance and management of all urinary catheter systems.
- Maintain a closed urinary drainage system in order to prevent infection and to maintain an unobstructed flow of urine through the catheter drainage system.
- At all times ensuring that the Client’s comfort, dignity and privacy is maintained.
- Each Client with an indwelling catheter will have an individualised specialised nursing care management plan which is developed with the involvement of the Client, and their family and/or representative and included in their care plan.
- Monitor skin conditions around the catheter
- Ensure proper positioning of catheter to maximize drainage.
- Recognize complications that may arise such as blockages, signs of infection.
- Escalate care appropriately.
- Maintain proper documentation.
- The Client’s catheter will be managed effectively taking into account the Client’s lifestyle, likes and dislikes and care needs. Clients with catheters will be cared for in a way that protects their privacy and dignity.
Definition
A catheter is a narrow, flexible tube introduced into the bladder to drain urine. It is held in place by a small balloon at the tip of the catheter. Inside the catheter there are two channels, one for drainage and one for inflating the balloon.
- Urethral catheters provide drainage of the urinary bladder when this is absolutely necessary. A sterile, closed to air, drainage system provides some protection against infection ascending into the bladder, and allows drainage of urine.
- An indwelling catheter is introduced via the urethra. Supra Pubic Catheter is introduced via a surgical opening in the abdominal wall.
Risk Management
The presence of a urethral catheter presents several possible risks to the Client:
- The presence of a foreign body within the urethra creates a bio-film between the urethral mucosa and the catheter, in which microorganisms can grow, and cause ascending infection.
- Micro-organisms may ascend up the lumen of the catheter, in air bubbles and due to back pressure. Micro-organisms introduced at the time of catheterisation also contribute to infection potential.
- Duration of catheterisation is strongly associated with the risk of infection. The longer the catheter is in place, the higher the incidence of urinary tract infection.
- Skin breakdown around the catheter insertion site as well as from indentation made by the catheter if it is not positioned appropriately
General Guidelines
- Only use urethral catheters after considering alternative methods of management in the case of intermittent catheterization
- The device should not be left indwelling unless absolutely necessary.
- Choice of catheter material will depend on clinical experience and Client assessment and anticipated duration of catheterisation.
- Select the smallest gauge catheter that will allow free urinary outflow. A catheter with a 10 ml balloon is normally used for indwelling catheters. Some Clients with urological complications may have larger gauge sizes and balloons.
- Catheterisation is an aseptic procedure.
- Clean the urethral meatus prior to catheter insertion.
- Use an appropriate sterile lubricant from a single dose container to minimise urethral trauma and infection.
- Connect indwelling urethral catheters to a closed urinary drainage system.
- Ensure that the connection between the catheter and the urinary drainage is not broken, except for good clinical reasons.
- Obtain urine samples from a sample port, or aseptic needle aspiration if required
- Position urinary drainage bags below the level of the bladder on a stand that prevents contact with the floor.
- When moving a Client, ensure the bag is kept lower than the bladder to prevent reflux.
- Empty the urinary drainage bag frequently enough to maintain urine flow and prevent reflux, preferably every shift and when necessary if it is ¾ of the bag full.
- Do not add antiseptic or antimicrobial solutions into urinary drainage bags.
- Do not change catheters unnecessarily or as part of routine practise.
- Routine personal hygiene is important to minimize infection risks.
Catheter Insertion
ICAH staff must understand the risks of infection and the rationale of procedures designed to prevent infection and be carry out correct techniques of aseptic catheter insertion and management.
Preparation for Procedure
Antiseptic handwashing and sterile gloves should be used when inserting an indwelling urinary catheter. This will prevent exogenous contamination and provide a barrier to avoid exposure of staff to the resident’s urine.
Handwashing
An antiseptic hand wash solution should be used and the hands dried with a clean paper towel. Site Preparation
- The perineal area should be cleaned using mild soap and water prior to catheterisation. If additional cleansing is required at the time of the procedure use 0.9% saline to cleanse labia minora and urethral meatus using downward strokes.
- A single use sachet of sterile lubricant or lignocaine jelly (prescription medication) is used to minimise friction/pain on insertion.
Aseptic Technique
- Catheterisation should be performed using an aseptic technique and sterile equipment to minimise entry of microorganisms to the bladder during the procedure.
- Discard catheter if it is accidentally contaminated during the procedure. Contamination includes any contact with the perineal area other than the urethral meatus. The catheter must be connected to the drainage bag maintaining asepsis.
Selection of Catheter
The smallest catheter compatible with adequate function should be selected to minimise urethral trauma. The anticipated length of time the catheter is likely to remain in situ, the reason for catheterisation, and the Client’s tolerance to catheter material should be considered.
- A catheter that is too large may produce urethral irritation, leading to urethritis and possibly to the development of urethral strictures. Pressure on blood vessels may produce tissue necrosis.
Securing the Catheter
- Indwelling catheters should be secured to the thigh after insertion in such a manner as to prevent unnecessary tension on the catheter within the urethra and urethral tract.
- The catheter tubing and drainage bag should be well positioned at all times to promote drainage and prevent reflux of urine from the bag to the bladder.
- The use of a leg bag should be encouraged and used for privacy and to prevent the drainage bag touching the floor/requiring a carrier.
- If a leg bag is not used, suitable drainage bag carriers should be used to hang the drainage bag on the bed or, for ambulatory Clients, to allow it to be carried.
- Drainage systems must not be placed onto the floor.
Documentation
following data should be documented in the Client’s record:
- date, time and reason for insertion type and size catheter
- volume of the balloon if applicable
- the recommended frequency for changing the catheter
Care of Catheter
- Whenever staff carry out catheter care they should take care to ensure the Client’s privacy and dignity is maintained at all times.
- A closed drainage system should be maintained with as few disconnections as possible.
- Interruption of the catheter and drainage system should be kept to a minimum and done using strict aseptic technique.
- Hands should be washed before and after any manipulation of the catheter system.
- If breaks in aseptic technique, disconnection or leakage occur, replace the system after disinfecting the catheter-tubing junction with alcohol swab or aqueous povidone iodine.
- Check the drainage bag each shift (or more frequently if required) and empty as necessary. Use alcohol wipe, disposable gloves and measuring jug.
- Change drainage bag weekly. Wear disposable gloves and swab connection with an alcohol swab prior to disconnecting.
- Overnight bags are connected directly to the drainage port in the leg bag. Ensure that the port in the leg bag is open to facilitate drainage overnight.
- Overnight bags are emptied and discarded each morning.
- The catheter site is washed with warm soapy water daily with the Client’s shower or sponge and after bowel actions.
- For male Client’s with a foreskin, retract, wash and dry and then ensure foreskin returns to its original position to prevent phimosis.
Troubleshooting
- If the catheter is not draining check for kinks, blockage indicated by sediment, adequate fluid intake, obstruction caused by constipation. The drainage bag may need to be lowered or be changed to one with a larger drainage tube to allow increased flow from the bladder. Increase fluids as tolerated and as discussed with the Client and care team.
- If blocked, the CCRN with a medical practitioner’s order may gently syringe the catheter with 50 mls of sterile water and a catheter tipped syringe. This is a sterile procedure. Drawing back should not be done as this may injure the urinary system.
- In some cases the catheter may need to be changed due to blockage or leaking.
- Change with the same size catheter or as directed by a medical
Collection of Catheter Urine Specimens for Culture
Specimens of urine from catheterised Clients must be aseptically obtained using an aspiration technique to avoid contamination of the specimen.
- Specimens should never be obtained by disconnecting the catheter from the drainage system. A closed system must be maintained to avoid introducing pathogens.
- Specimens must never be collected from the drainage bag. Such specimens only indicate the microorganisms in the drainage bag and not in the urinary tract.
Method of Collection
- Write on the specimen jar prior to collecting the specimen.
- Wash hands with antiseptic preparation.
- Clamp drainage bag tubing just below Catheter/Drainage Bag connection.
- Put on clean gloves, sterile gloves are not necessary.
- Disinfect port with 70% alcohol swab and allow 15 seconds to dry.
- Aspirate 5-10 mls urine.
- If needle and syringe used, transfer urine to sterile labelled container.
- Disinfect port with 70% alcohol swab to remove any urine.
- Remove clamp.
- Send specimen to the Client’s designated lab as soon as possible, together with a completed request form noting this is a CSU. (Catheter Specimen of Urine)
- Refrigerate the urine at 4 degrees C to retard the degeneration of cells and multiplication of microorganisms. The urine will be suitable for culture for 24-48 hours if kept at 4 degrees C.
Suprapubic Catheter
A suprapubic catheter is a tube inserted into the bladder through the abdominal wall to drain urine from the bladder.
Advantages of suprapubic catheterisation:
- More hygienic as it is away from the genital area where infection has an easy passage to the bladder via an indwelling urethral catheter.
- Easier to change and less embarrassing for the Client, relatives, etc.
- Pressure areas can occur with urethral indwelling catheters.
Disadvantages of suprapubic catheterisation:
- Catheter must be replaced immediately if it falls out as the opening may close over.
- Urine may still leak via the urethra especially if catheter is blocked or the drainage tube kinked.
- Any tube going into the bladder can provide an entry for infection.
- Some Clients are not comfortable with the thought of a tube going into their abdomen.
Care of a Suprapubic Catheter
- Check the catheter site daily for signs of infection or irritation (look for redness, feel for heat at site, check for discharge). If you feel there is a problem, discuss with the Client and notify care team.
- Personal hygiene and thoroughly clean and dry around the catheter site.
- Avoid the use of talcum powder, sprays or deodorants around the site of the catheter.
- Ensure the drainage bag is below the level of the waist to allow the urine to drain by gravity (unless wearing a waist bag).
- Maintain a closed drainage system as much as possible. This means keeping the number of times you have to disconnect the bag to an absolute minimum. This will reduce the chance of getting infections.
- Always have a spare supra-pubic or urinary catheter available in case of emergencies, follow Client’s care plan for escalation.
- Never take the catheter out unless one is going to be re-inserted immediately.
Changing of the suprapubic
- Changing of the suprapubic catheter should be maintained on the care plan and followed up with the Client and the Client’s care team. Care plans are discussed in team meetings every quarter. Supra-Pubic Catheter changes should be done as designated by practitioner/team on the care plan.
- Rotate the SPC 360 degrees each day.
- Secure the catheter to the abdomen with mefix or a catheter waist strap
Intermittent ‘in / out’ catheterisation
Intermittent ‘in / out’ catheterisation should be considered when a urinary catheter is required to be inserted and removed immediately after the completion of drainage. Intermittent ‘in / out’ catheterisation is appropriate for the alleviation of urinary retention or obstruction (e.g., neurogenic bladder) or for certain urgent investigations (e.g., collection of a catheter urine specimen). Clinical contraindications for intermittent ‘in / out’ catheterisation is:
- Urethral stricture
- Urethral reconstruction
- Clot retention
- Known or suspected urethral trauma
- Thrombolytic therapy for stroke
- Conditions where continuous drainage is required
- Urethral orifice cannot be identified or accessed due to injury, obstruction or urogenital atrophy.
Repeated intermittent catheterisation may be undertaken, however repeated insertions may increase the risk of trauma to the insertion site and urethra and may increase the risk of introducing microorganisms into the bladder. Ensure that the catheter is well lubricated to minimise insertion trauma. Intermittent catheterisation an aseptic procedure. Document on the Client’s record appropriately and in collaboration with the Client notify Care team for urinary retention issues.
Procedure for Emptying a Urine Bag
Hand hygiene must be performed using alcohol-based hand rub and soap and water as per infection prevention and control procedures.
- Collect all necessary equipment.
- Wash and dry your hands before and after emptying the bag.
- Wear disposable gloves.
- Use a clean designated jug large enough to avoid spillage e.g., 2-3 Litres.
- Clean the catheter outlet with an alcohol wipe.
- Empty the catheter by opening the outlet at the bottom of the catheter bag.
- Do not allow the outlet to touch any surfaces.
- After emptying the bag, wipe the end of the catheter outlet with an alcohol swab.
- Close the outlet on the bag.
- Note the amount and colour of drainage and record it
- Empty jug carefully into the toilet
- Clean the jug with soap and water and or Client preferences for cleaning procedures.
Potential Complications
- Discoloured or strong-smelling urine
- Dark strong-smelling urine may indicate dehydration. Review intake with the Client and consider increase as needed unless contraindicated, and If so contact Care team in collaboration with the Client.
Urinary tract infections
Signs of an infection include:
- cloudy, bloody or smelly urine
- feeling unwell, fevers, chills or shaking
- bladder, pelvic, lower back or flank pain.
If any of these symptoms occur, consult with the Client, escalate care to the care team as soon as possible and follow the treatment plan. Create an incident report for escalation of care.
Post Infection Management
ICAH recommends the following in the event that a client is on a course of antibiotics for urinary tract related infections to be performed per policy:
- A urine dipstick two days after completion of antibiotic treatment
- Another urine dipstick 7 days post antibiotic treatment
Bladder spasms and bypassing, no drainage
Check the following:
- How long has the catheter been in place?
- Is the tubing bent or kinked?
- Is the bag below the bladder level?
- Is there sediment in the tubing which is blocking the catheter?
- Is the Client properly hydrated?
- Try repositioning the Client,this may dislodge the blockage.
- If no urine has passed in four hours, contact the client’s Care team.
References:
- Royal Children’s Hospital Melbourne, 2020. Indwelling Urinary Catheter-Insertion and Ongoing Care. Available from: Clinical Guidelines (Nursing) : Indwelling urinary catheter – insertion and ongoing care (rch.org.au)
- Caring for a Urinary Catheter. Available from: Urinary Catheters: Overview, Care & Assessment | Ausmed
- Australia and New Zealand Urological Nurses Society, 2014. Catherisation Clinical Guidelines.
National Disability Insurance Scheme, 2020. NDIS Practice Standards and Quality Indicators. Available from: https://www.ndiscommission.gov.au/providers/ndis-practice-standards